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Health History Form (FOR CONSULT)
Welcome to Your Health Journey!
We're excited to help you on your path to better health. Please fill out this form to help us understand you better. Your honest answers will help us provide the best support.
Enter your Name
*
Getting to Know the Client
Full Name of client
*
*
Email ID of client
*
Phone Number
*
Emergency Contact Number
Date of Birth
*
Age
*
Occupation
*
City (Location)
*
Gender
*
Your Current Health Snapshot
Height (in centimeters)
Current Weight (in kilograms)
Waist Circumference (in inches)
What are your primary health goals?
What are your primary health goals?
Boost Energy Levels
What are your primary health goals?
Improve Sleep Quality
What are your primary health goals?
Manage or Reduce Stress
What are your primary health goals?
Achieve a Healthy Weight
What are your primary health goals?
Enhance Digestion & Gut Health
What are your primary health goals?
Strengthen Immunity
What are your primary health goals?
Increase Physical Fitness/Stamina
What are your primary health goals?
Reduce Chronic Pain/Inflammation
What are your primary health goals?
Improve Mental Clarity & Focus
What are your primary health goals?
Balance Hormones
What are your primary health goals?
Detoxification/Cleansing
What are your primary health goals?
Better Skin/Heair Health
What are your primary health goals?
Learn Healthier Eating Habits
What are your primary health goals?
Prevent Future Health Issues
What are your primary health goals?
Increase Overall Well-Being
What are your primary health goals?
Other
Primary Health Goal (Client's Response)
Understanding Your Health History
Do you have any existing medical conditions or current health issues?
Are you currently taking any medications or supplements?
Are you currently taking any medications or supplements?
A
Yes
Are you currently taking any medications or supplements?
B
No
Do you have any allergies or experience side effects to anything (food, medications, etc.)?
Do you have any allergies or experience side effects to anything (food, medications, etc.)?
A
Yes
Do you have any allergies or experience side effects to anything (food, medications, etc.)?
B
No
What are the main symptoms or concerns that led you to seek health support? (e.g. fatigue, digestive issues, pain)
Have you received a COVID-19 Vaccination?
Have you received a COVID-19 Vaccination?
A
Yes
Have you received a COVID-19 Vaccination?
B
No
Your Lifestyle & Habits
Select your Dietary Preferences:
Select your Dietary Preferences:
A
Vegetarian
Select your Dietary Preferences:
B
Vegan
Select your Dietary Preferences:
C
Non-Vegetarian
Select your Dietary Preferences:
D
Eggetarian
Select your Dietary Preferences:
E
Other
Can you describe your typical daily meals & timings?
How often do you consume sweet or sugary foods?
How often do you consume sweet or sugary foods?
A
Rarely
How often do you consume sweet or sugary foods?
B
A few times a Week
How often do you consume sweet or sugary foods?
C
Daily
How often do you consume sweet or sugary foods?
D
Multiple times a day
What type of cooking oil do you primarily use?
Do you experience any Digestive issues?
Do you experience any Digestive issues?
Bloating
Do you experience any Digestive issues?
Constipation
Do you experience any Digestive issues?
Diarrhea
Do you experience any Digestive issues?
Heartburn / Acid Reflux
Do you experience any Digestive issues?
Gas / Flatulence
Do you experience any Digestive issues?
Abdominal Pain / Cramping
Do you experience any Digestive issues?
Food Sensitivities / Intolerances
Do you experience any Digestive issues?
Irregular Bowel Movements
Do you experience any Digestive issues?
None of the above
Do you experience any Digestive issues?
Other
Do you consume Alcohol?
Do you consume Alcohol?
A
Yes
Do you consume Alcohol?
B
No
Do you smoke?
Do you smoke?
A
Yes
Do you smoke?
B
No
How much water do you typically drink in a day? (in Litres)
How would you describe your sleep patterns?
How would you describe your sleep patterns?
I fall asleep easily but wake up often during the night.
I struggle to fall asleep initially.
I wake up too early and can't get back to sleep.
I sleep through the night but still feel tired in the morning.
My sleep schedule is very irregular (e.g., shifts, varying bedtimes).
I often snore loudly or have been told I do.
I wake up frequently to use the restroom.
I rarely remember my dreams.
I generally have restful and refreshing sleep.
Describe your exercise routine
How would you rate your current stress level on a scale of 1 to 10?
How would you rate your current stress level on a scale of 1 to 10?
1
2
3
4
5
6
7
8
9
10
Lowest
Highest
A Little More About Your Journey
Do you feel a strong sense of ownership over your body and health?
Do you feel a strong sense of ownership over your body and health?
A
Yes
Do you feel a strong sense of ownership over your body and health?
B
Mostly
Do you feel a strong sense of ownership over your body and health?
C
Sometimes
Do you feel a strong sense of ownership over your body and health?
D
Not really
How responsible do you feel for what you consume (food, information, etc.)?
How responsible do you feel for what you consume (food, information, etc.)?
A
Very responsible
How responsible do you feel for what you consume (food, information, etc.)?
B
Moderately responsible
How responsible do you feel for what you consume (food, information, etc.)?
C
Less responsible
What role do you see us playing in your health journey?
Beyond your personal well-being, how do you envision achieving your health goals might positively impact others or humanity in general?
What are you hoping to learn or grow in regarding your health through this experience?
Submit
